Review: An Anthropologist Looks at Heroin Addiction

By Parker Bernal and Diana Cabrera

The Pastoral Clinic: Addiction and Dispossession Along the Rio Grande
Angela Garcia
University of California Press (2010), 265 pages

During a normal night as an attendant in the Nuevo Dia’s detoxification clinic in the Espanola Valley, patients approach Angela Garcia for “algo” — something to remove their physical and psychological pain.

Then the sole late night attendant on a night that included a power outage, she gives readers a palpable sense of the abysmal pit of heroin addiction and unfair distribution of resources in this under-resourced clinic. In The Pastoral Clinic: Addiction and Dispossession Along the Rio Grande, Garcia writes:

For the next three hours I deflected growing demands for something by filling bowls with vanilla ice cream and permitting the use of the boom box. Soon the sounds of Tejano and hip hop filled the clinic. Though the volume was turned up high, the music inspired no movement, no recognition. The patients sat motionless on tattered couches, their eyes fixed on a clock hanging on the wall. At one point a young addict named Yvette said that she felt like we were stuck on a deserted island. Together, we waited for the dosing hour like the arrival of a rescue plane. (p. 45)

Pop quiz: Where is the highest concentration of heroin-related deaths in the United States? New York? Chicago? Los Angeles? Seattle? It is unlikely that you considered the remote town of Espanola Valley, New Mexico, near the Los Alamos National Laboratory.

The sad truth is that 30,000 people in the Espanola Valley are addicted to heroin. Surprisingly, this figure represents the highest addiction rate and the highest number of fatal overdoses in the United States due to heroin abuse.

A Metaphor for Heroin Addiction

The Pastoral Clinic has garnered Garcia academic recognition and two book prizes. A native of the valley, she earned her doctoral degree in medical anthropology at Harvard University, and she is now an associate professor at Stanford University, where she conducts research south of the border in urban environs (i.e., Mexico City) to analyze developing discursive and social relations connected to poverty, mental illness, and drug addiction.

Garcia developed an intimate knowledge of heroin addiction in the valley by develop-ing relationships with addicts while working in the only clinic in the region.

As an outsider to the drug culture, Garcia relays observations, stories, and analysis of Nuevo Dia and its patients to convey aspects of the problem. In describing her relationship with heroin addiction, she writes, “These forms of experience exclude me, and yet they concern me; heroin overdose is endemic to the region (and may thus be considered ‘collective experience’) and yet, in the end, is a solitary act” (21).

This sentiment disrupts the mainstream narrative of the hedonistic individual deciding to abuse drugs for recreational reasons or their own selfish needs.

Garcia’s ethnographic study reveals her immersion into the lives of addiction and provides an intimate and insightful account into an experience that few can access. She returned to the arid geographic landscapes of her childhood community to grapple with the region’s history, politics, and culture in relation to ubiquitous and destructive drug addiction. This act of relocation enables her to thread together a unique set of connections shaping this public health issue. Garcia writes in the Preface:

A central theme in this book is how loss and mourning provide more than a metaphor for heroin addiction: they trace a kind of chronology, a temporality, of it. They even provide a constitutive power of it (p. 7).

Garcia considers how addiction is a disease emerging from the need to numb invisible communal suffering produced by historical and ongoing trauma. “The word people often use for heroin in northern New Mexico is ‘medicina,’” Garcia explained in a recent interview. “They view heroin as just another medication that takes pain away.”

Garcia developed an intimate knowledge of heroin addiction in the valley by developing relationships with addicts while working at the only clinic in the region. As a consequence, The Pastoral Clinic shows the relationship between self-medicating and the regional geographic and cultural dispossessions that have led to displacement, marginalization, addiction, and communal pain.

Both her narration and her analysis illuminate the lives of the area’s heroin addicts residing, and shows how heroin addiction among the members of the local Hispanic community is a result of the history of dispossession, family dynamics, and the indigenous Hispanic culture. In exploring the intergenerational dimensions of heroin addiction among Hispanos, she reveals that the drug provides a source of bonding among family members and friends, and anesthetizes their nostalgic sense of loss.

In doing so, Garcia draws on Sigmund Freud’s “Mourning and Melancholia” to introduce the readers to the idea of “melancholy subjectivity.” She writes, “Melancholy … designates a kind of mourning without end. It entails an incorporation of the lost person or ideal as a means to keep it alive and thus suggests that the past  that is the lost past  remains persistently present” (p. 75). The idea of historical trauma creating an open wound is used to explain how the local Hispanic tradition and isolated environment disallow these individuals to forget about their problems.

The Pastoral Clinic reveals how a trans-generational cycle of mourning “sin termina” (without end) is partly created by the community’s geographic isolation, and history, and the Hispanic nostalgic tradition to honor and idealize the past impedes inhabitants of the valley from moving forward. Hence, historical memory and subjectivity interact to create a need for “algo” to take away the pain.

An Inside View

Instead of observing the clinic from afar, Garcia became a detox attendant there ― administering medications, preparing meals, and facilitating group counseling sessions. She developed relationships, and experienced the enormity of the health crises to gain more personal knowledge.

She discovered three challenges to the Nuevo Dia clinic's providing effective heroin addiction:

There are few resources available to the clinic.

The clinic has limited skilled staff members.

The environment outside the clinic is not conducive to maintaining a “clean” lifestyle.

The professor’s insider-outsider status is portrayed in the opening pages when Garcia describes her first night on the graveyard shift, as the power goes out while she deals with a clientele that she describes as addict and offender, patient, and prisoner. Her initial encounters with the patients touched on the greatest challenge that the clinic faces: “la vida afuera,” which translates to “life outside” (191). On the outs, patients must deal with their dysfunctional familial bonds involving “the complex politics of kin, love, and mourning” (149). Garcia portrays life in the Espanola Valley as a profoundly neglected community with severe problems of heroin addiction and overdose.

The theme of intergenerational heroin addiction in the Espanola Valley occurs often in the addicts’ recounts of their downward spiraling journey into addiction. Bernadette and her mother, Eugenia, demonstrate this point. Bernadette claims, “I was born a heroin addict. It’s in my blood” (p. 115). Garcia observed that in similar cases the actions of individuals and family members interact to produce an inescapable web of bondage that ensnares an entire community. Yet the generational influence could also discourage addiction.

By starting a new life and having a son, Joseph rose to success in overcoming his addiction. Garcia describes him as “a legend” among Nuevo Dia men’s support group because of his success in ending his “war with heroin” (p. 105). And Joseph isn’t the only subject to transcend bondage to heroin addiction in the Espanola Valley.

Alma left the clinic to join the Rock Christian Fellowship. She explained to Garcia that faith allowed her to move past failure and trauma to a more open future.

I shouldn’t have gone back. I’ll tell you something: that place don’t work. Its focus is all wrong. They want you to always be thinking about what you did, why you did it, how you’re always gonna be an addict …You’re always ’ceptible to heroin, and there’s no cure. ... [That’s why] I like it here [at the church]. They’re not always looking back, you know? The pastor talks about the future; he says that’s what counts …. (87)

Alma’s story shows the relationship between the psychological, emotional, and spiritual dimensions of heroin addiction ― and how faith enables one to find a community and hope for transcending a hopeless existence.

As Christian students interested in how practitioners in medicine and psychology can unintentionally reproduce the effects of structural violence that medicine is intended to heal, we saw that the ubiquitous addiction to heroin among the Hispanic population in The Pastoral Clinic had less to do with ethnicity or race than the book implies.

Quite honestly, I (Parker) saw it as a marginalized population of Hispanics rather than the population as a whole. It was less about Hispanic culture, and more about geography and history. Generational influence was portrayed in such a negative way that it didn’t show the strength of family ties.

And I (Diana), a Latina, felt the heroin use in this community wasn’t caused by race, because it is not limited to Hispanic people. In fact, one sees similar dynamics in isolated white communities’ usage of hydrocodone and methamphetamines. We felt these oversights undermined the author’s credibility. As a Spanish speaker, I also don’t feel Garcia did the best job at translation, translating words in order to fit her arguments.

But in the end, Garcia’s book The Pastoral Clinic contributes a new perspective when looking at heroin addiction for readers and the field of medicine as a whole.

The touching, challenging, and intimate narratives of each of the Espanola Valley locals are intricately woven with Garcia’s insightful analysis making the book both gripping and interesting. We highly recommend The Pastoral Clinic, especially to those interested in ethnography, addiction, medical ethics, and social justice.

The Pastoral Clinic may change you; it may broaden your perspective; it may deepen your understanding; and it may cultivate a desire in you to improve justice and care in places like the Espanola Valley.

Parker Bernal was born and raised in Denver, Colorado. A freshman at Seattle Pacific University, she is studying history and intends to pursue medical school.

Diana Cabrera was born in Mexico City, Mexico. Also attending Seattle Pacific University, she intends to major in physiology as a pre-med student.